The majority of workers’ compensation claims are straightforward, and in most cases, the cause of the injury and the relationship to the workplace are clear. However, there are a few types of claims that fall into more of a gray area. Employers should understand that just because someone is hurt or injured at work does not necessarily mean a claim should be accepted and paid for by the employer or their insurer.
The legal term for these spontaneous injuries is “idiopathic,” meaning they originate due to something personal to the claimant, not the workplace. An obvious example of an idiopathic incident would be a seizure. It might take place at work, but work is not the cause of the incident or injury. Other injuries are less clear-cut: If someone stand ups from a desk and herniates a disc in their back, is that spontaneous or work-related?
Workers’ compensation claims must meet four standards to be accepted as compensable:
- There is an accident;
- There is an injury;
- It happened while at work or while performing work; and
- The work caused the accident
Let’s take a look at each of these criteria and examine how circumstances could lead to a ruling of a claim being compensable.
An Accident Happens
A specific incident resulting in an accident must occur.
An Injury Results from the Accident
A claimant must have an injury occur as a result of the accident. Example: if a worker is in an automobile accident, but they are not injured, then the claim should not be accepted as compensable.
How Was the Workplace Involved?
Just because an incident happens while an employee is working does not mean that it should be an accepted claim. If someone has a seizure and is injured, this would be idiopathic and should be denied. However, injuring your arm as a result of lifting something at work would be compensable.
Did Work Cause the Accident?
If an employee is in bad health and has a heart attack or stroke while working, then the claim can be denied, arguing that work did not cause the accident. It is the employees’ personal health condition that caused the event while they were working.
Was the Employee Working?
The employee must be benefiting the employer at a time and place where they are expected to be working. If an employee has taken their own car to pick up supplies for a meeting and has an accident on the way, then the claim is compensable. If, however, they also decide to stop at the ATM and the library on her way and has an accident between those two stops, then the claim should be denied based on a deviation.
Because these claims are challenging to prove or disprove, a little prep work ahead of time can make the experience easier. There are several ways you can prepare your company now to deal with claims later:
Posted Panel of Physicians: Your company should get with your insurance company to create its own medical panel as required by law. Encourage employees to treat with a panel doctor. Do not put a hospital on the list, because then every physician at the hospital becomes a part of your medical panel.
Post-Hiring Health Questionnaires: Have all new hires fill out a detailed health questionnaire (update annually). If they don’t acknowledge a prior history with an injury, then their claim may be denied. Part of the process is to read the questionnaires and make fitness assessments. If you see an employee has a history of herniated discs, you might avoid assigning heavy lifting duty.
Speedy Interviews: Interview the injured worker and any witnesses as soon as possible. Document this in writing and place the information in the worker’s compensation file, which is kept separate from their personnel file. Stories tend to change over time, so lock it down quickly.
Delay Benefit Payments: When you only have a certain amount of time (it varies by state; 81 days in Georgia) to investigate a claim, don’t pay benefits immediately. If there is any question of legitimacy, it is more advantageous to deny the claim initially and then investigate thoroughly.
Returning to Work: If you can return the employee to light duty work as soon as practical, it’ll reduce your payout. Make sure you make the offer in writing, and with a list of specific duties entailed that are consistent with the work restrictions from the treating doctor.
Compassion: A little compassion goes a long way. Regardless of whether the claim will be paid or not, keeping on good terms and checking on the injured worker benefits everyone. Visit the employee at home or in the hospital. Workers who feel appreciated are less likely to get an attorney.
Doug Rieder is president and principal with Sterling Risk Advisors (www.sterlingra.com).
Kim A. Roper and Harry R. Tear, are attorneys with the firm of Moore Ingram Johnson & Steele (www.mijs.com)